Knowledge, Attitude, and Practice of Emergency Medical Services Staff in Bleeding Control of Trauma Patients; a Cross sectional Study

Introduction: External hemorrhage is a leading cause of preventable death due to trauma and Emergency Medical Services (EMS) staff members play a vital role in the frontline of trauma management. This study aimed to assess the knowledge, attitude and practice of EMS staff in bleeding control. Methods: This knowledge, attitude and practice (KAP) study was conducted to assess the educational needs of EMS staff of Hormozgan province, Iran, regarding the bleeding control of trauma patients, during 2019. The participants were randomly selected and then their knowledge, attitude, and practice in management of hemorrhage and hemorrhagic shock were assessed using two researcher-made scenario-based questionnaires and one checklist. Results: The scores for knowledge of the EMS staff regarding actions during complete amputation, status of injured patients, and medical measures during transfer of injured patients were 3.22 ± 0.68, 2.28 ± 0.83, and 2.29 ± 0.62, respectively. The average participants' attitude scores regarding the fear of bleeding, the importance of bleeding control, and confidence in bleeding control were 2.09±0.56, 2.4±0.58, and 1.76±0.55, respectively. The findings indicated that mean practice score was 1.72 ± 0.46 in capillary hemorrhage control, 1.41 ± 0.25 in venous bleeding control, 1.47 ± 0.25 in arterial bleeding control, and 1.56±0.27 in control of bleeding in the amputee limb. Conclusion: The knowledge, attitude, and practice of EMS staff regarding bleeding control were moderate, positive and appropriate, and incomplete, respectively. Since bleeding is a life threatening status and EMS staff skills are critical in this issue, it seems that we need to provide continuous education in this regard.


Introduction
Road traffic deaths are expected to increase to 2 million per year by 2020, which will mostly occur in developing countries, especially in South Asian countries (1). Acute, lifethreatening hemorrhage after trauma is a major cause of early mortality after trauma, accounting for 40% of trauma deaths globally (2,3). Managing a multiple trauma patient in the presence of severe hemorrhagic shock is naturally a challenge (4). Although active bleeding in the organs or local bleeding may be tem-mortality and improving patients' outcome (6). Out of the 31,058 pre-hospital missions accomplished in 2017 in Hormozgan province, Iran, 13,103 were related to road accidents and traumas (7). To increase the chance of a patient's survival, several national agencies, including the American Surgeons Committee on Trauma, have attempted to highlight the importance of rapid response to hemorrhage (9). Although the management of bleeding slightly varies between different systems, the overall methods are similar and are in accordance with the general principles of advanced trauma life support (ATLS) protocol (10). Identifying the strengths and weaknesses of EMS staff in this regard, and improving the quality of their approach is very important (11). Therefore, this study aimed to evaluate the knowledge, attitude and practice of EMS staff in bleeding control of trauma patients.

Study design and setting
This knowledge, attitude and practice (KAP) study was conducted during a 1-year period in 2019 to assess the educational needs of EMS staff of Hormozgan province, Iran, regarding bleeding control of trauma patients. The participants were selected from EMS staff of the province and then their knowledge, attitude, and practice in management of hemorrhage and hemorrhagic shock were assessed using two scenario-based questionnaires and one checklist. The study protocol was approved by Ethics Committee of Shahid Beheshti University of Medical Sciences, Iran, receiving the ethical code IR.SBMU.PHARMACY.REC.1398.27.

Participants
All pre-hospital emergency staff members working in the EMS stations of Hormozgan province were selected using census sampling method. Having at least an associate degree in medical emergencies or a bachelor's degree in nursing, and experience of working in the pre-hospital emergency unit were among the inclusion criteria. The staff members working in the administrative unit of pre-hospital emergency or the dispatch unit were excluded.

Data gathering
The data collection tools developed by the research team included a demographic survey, two scenario-based questionnaires for assessing the knowledge (appendix 1) and attitude, and one checklist for evaluating the practice of EMS staff regarding bleeding control in trauma patients. Questionnaires were given to ten experts to assess their face and content validity, which were confirmed after making modifications. To assess the reliability of the questionnaires, they were reevaluated by 10 experts after a week. The intra-class corre-lation coefficient (ICC) was 0.9. Also, the reliability of the checklists was assessed using inter-rater agreement coefficient (0.85). A demographic survey consisting of 8 items based on personal information and work experience of EMS personnel in the pre-hospital setting was used to gather the data of the participants. The data were collected by an emergency nurse with a master's degree. In order to collect data, the researcher referred to the pre-hospital emergency units of Hormozgan province. The researcher visited pre-hospital emergency services in Hormozgan, and following coordination with authorities and obtaining consent from the pre-hospital staff members, first, the demographic survey and the knowledge domain questionnaire were given to the participants. Then the attitude domain questionnaire was given to the participants, and the filled out questionnaires were collected. Finally, a moulage was used to assess their hemorrhage control skills. After simulating the various vascular injuries on the moulage, emergency personnel were asked to perform remedial measures based on the checklist questions. Then the scores for each section were recorded in the checklist by the researcher.

Knowledge assessment tool
In order to assess the Knowledge level of participants, a questionnaire containing two scenarios in the form of Key Feature Problem (KFP) was used. Scenario 1 consisted of four questions regarding Arterial Bleeding Control and Scenario 2 included three questions regarding the management of amputated injuries. Knowledge of EMS staff in this domain was evaluated and given a score from 0 to 4. The knowledge score of the participants was categorized as low (mean score < 2), moderate (mean score: 2-3), and high (mean score: 3-4).

Attitude assessment tool
A questionnaire consisting of 14 items was used to survey the participants' attitude toward bleeding and shock control measures. Attitudes questionnaire was set based on a 5-point Likert scale from "totally agree" to "totally disagree". Scores of the participants' attitude were categorized as follows: negative attitude (mean score: 3.5-5), moderate attitude (mean score: 2.5-3.5), and positive attitude (mean score: 1-2.5).

Practice assessment tool
After simulating various vascular injuries on the moulage, the included EMS staff members were asked to perform remedial measures based on the checklist questions and the scores for each section were recorded in a checklist. The checklist was used to evaluate the hemorrhage control practice including capillary, venous, and arterial hemorrhage, as well as amputation management. Skill of staff in doing each item was calculated as correct receiving 2 points, incomplete or incorrect

Statistical Analysis
Collected data were analyzed using SPSS software version 21. Mean ± standard deviation or frequency (%) was used for reporting the findings. For investigating the relationship between knowledge, attitude, and practice with demographic characteristics of participants, analysis of variance (ANOVA) was used. P<0.05 was considered as significant.

Baseline characteristics of studied EMS personnel
165 EMS staff members with the mean age of 34.68 ± 5.11 years were evaluated (100% males). The demographic characteristics of the participants are presented in Table 1. 49.1% of the participants were in the 36-45 years age group, 133

Attitude of participants
The average attitude score of the participants regarding the fear of bleeding, the importance of bleeding control, and confidence in bleeding control were 2.09±0.56, 2.4±0.58, and 1.76±0.55, respectively (table 3). The ANOVA results demonstrated that there was a significant association between of attitude of EMS staff and type of employment (p = 0.07).

Practice of participants
The total hemorrhage control proficiency score of the participants was 1.54 ± 0.25. The findings indicated that the mean practice score was 1.72 ± 0.46 in capillary hemorrhage control, 1.41 ± 0.25 in venous bleeding control, 1.47 ± 0.25 in arterial bleeding control, and 1.56±0.27 in bleeding control of the amputee limb (table 4). There was a significant association between the practice levels of EMS staff and age (p = 0.001), marital status (p = 0.001), educational level (p = 0.001), type of employment (p = 0.001), work experience in EMS (p = 0.001), and work experience in hospital (p = 0.001).

Discussion
The results of the present study showed that the knowledge, attitude, and practice of the studied EMS staff regarding bleeding control were moderate, positive and appropriate, and incomplete, respectively. Findings by Ghaffari et al. suggested that the most important educational need of pre-hospital centers is cardiopulmonary resuscitation educational course, and a training course on examining consciousness level of the injured. In addition, three training courses were introduced as high priority courses for hospital emergency care centers, which included courses on how to deal with specific cases (such as amputation and bleeding control), advanced burn training courses, and Advanced Trauma Life Support, all of which had the same degree of importance, followed by self-care educational course in road accidents. The study indicated the necessity for formulating and holding educational programs on the extracted priorities to promote the skills of staff in prehospital and hospital centers (12). In the first scenario of this study, findings indicate that participants had moderate performance in examining injured person's condition, diagnosis of severity of hemodynamic status, taking immediate measures to protect the injured person, and therapeutic measures during the transfer of the injured person. In addition, regarding the second scenario, their decisions for preserving the incomplete amputated limb and tightening the tourniquet was categorized as average; however, they had better decision-making regarding acting for complete amputation and were ranked as good. The studied EMS personnel had a positive attitude toward fear of bleed-ing and shock as well as hemorrhage control, but given the importance of hemorrhage control and its irreparable consequences, more attention should be paid to these skills and EMS personnel need more training in this regard. In their study, Parvaresh et al. compared the effects of scenariobased and lecture-based education methods on knowledge and attitude of emergency medical technicians towards patients with chest trauma and the results showed that in the scenario-based education method, the mean knowledge and attitude scores were significantly higher (p <0.001). Given the impact of scenario-based education and its role in making use of the learner's intellectual abilities and their creativity, scenario-based education seems to be an appropriate alternative to traditional teaching methods (13). Regarding hemorrhage control practice, findings indicated that in capillary bleeding control, the highest score belonged to examining the extent of capillary bleeding and the majority of staff paid attention to it. In addition, they often covered the entire surface of injured site correctly. However, paying attention to the clotting at the wound site, and not manipulating the site of bleeding was less considered. The average performance of the emergency personnel was satisfactory. Regarding venous bleeding control, the findings showed that the majority of staff cleaned or rinsed the area correctly to identify the bleeding area and paid close attention to the lower limbs for the purpose of examining the continuation of bleeding. However, they were less skilled in using pressure patching in case of bleeding and not eliminating the original gauze layer on the site. In addition, despite having sufficient skill in applying pressure on the site, the majority of the staff showed negligence to maintaining pressure on the site for 3 minutes, their average performance was not generally satisfactory. Regarding arterial bleeding control, the findings showed that the majority of staff paid close attention to the exact location of the released artery and the use of direct pressure on the site. But they did not show mastery on the use of pressure points for the arm and thighs. In terms of using the tourniquet, they didn't pay attention to tightening the tourniquet and observing the joint. The majority knew that they should expose the injured limb and use the symbol of the tourniquet. However, their performance was poor regarding the last stage of using tourniquet, i.e. loosening the tourniquet, for creating mild bleeding current in order to preserve distal limb. Their average performance was not generally satisfactory. Regarding bleeding control in amputated limp, it was found that less attention was paid to sterility of dressing on the wound site. In addition, they did not show mastery on bandaging the amputated limb. However, they observed exposure of the amputated limb. Their average performance was not generally satisfactory. In the study by Oyeniyi  Results indicated that mortality did not correlate with gender and race, and the main factors resulting in death were brain damage and bleeding. By implementing this training package, mortality due to bleeding dropped from 36% to 25% (14). The results of the Down Port study on pre-hospital controlling of bleeding in traumatic patients indicated that the most common cause of traumatic deaths is bleeding, which usually occurs within three hours of injury. This study indicates that identification of severe bleedings should be performed as part of the primary evaluation on the scene, and potential clinical interventions should be performed as soon as possible. Effective treatment of bleeding in the pre-hospital phase depends on quick identification of severe bleeding, direct anatomic control of vascular damage, bleeding restoration, and transfer to hospital (15). There is a need for formulating in-service educational courses to eliminate any deficiencies in bleeding control and improve the knowledge of pre-hospital emergency personnel for enhancing decision-making.

Limitation
Special job condition and personal problems might have affected the psychological condition of the participants at the time of completing the questionnaire and this might have affected the answers given; however, this was out of the researchers' control. Additionally, observing the staff when implementing bleeding control skills might have influenced their performance.

Conclusion
The knowledge, attitude, and practice of the studied EMS personnel regarding bleeding control were moderate, positive and appropriate, and incomplete, respectively. Since bleeding is a life threatening condition and EMS staff skills are critical in this issue, it seems that we need continuous education in this regard.